question

Who is the current CEO of AHIMA?

answer

Edna K. Huffman

question

Is there electronic completion of birth certificates?

answer

no

question

What year was HIPAA developed?

answer

1996

question

The organization that acts as an accreditation body for medical schools and residency programs is called the:

answer

AMA

question

What is another name for Medicaid?

answer

Title XIX

question

When a patient is readmitted, receives a new MR#, but previous records are kept under their original numbers, this is what type of numbering?

answer

serial

question

The AIS stands for what and is associated with what registry?

answer

abbreviated injury scale, trauma registry

question

The condition that is chiefly responsible for occasioning admission is called the:

answer

principal diagnosis

question

Multiple encounters are filed in separate locations using what type of film system?

answer

microfilm jackets

question

Care provided through hospice is called what?

answer

palliative care

question

Rehabilitation facilities use what assessment form?

answer

PAI

question

Long-term care facilities use what assessment form?

answer

RAI

question

The patient's legal status is unique to what care setting?

answer

behavioral health

question

A dental exam is unique to which care setting?

answer

correctional health care

question

A problem list is found in what care setting?

answer

ambulatory

question

What care setting has two episodes of care?

answer

hospice

question

In what type of care is means of arrival pertinent information?

answer

emergency

question

Certification of a healthcare facility allows them to participate in the _______ program.

answer

Medicare

question

A facility is deemed to be in compliance with licensure and certification standards if _________ accreditation is achieved.

answer

JCAHO

question

The correct level of detail is defined for data attributes and values in:

answer

granularity

question

What hospital started the first patient register?

answer

new york hospital

question

Providing information and communication services to the community, admission and registration of patients, pre-registration, and compiling data for A/D/T are all functions of the:

answer

admitting office

question

What elements would be found in a disease or operation index? (4)

answer

MR#, age, race, gender

question

When SOAPed progress notes are numbered, they correspond to what?

answer

problem numbers on a problem list

question

Name two things that can be found on an outguide.

answer

requisition slip, lab or other reports not attached to the record

question

Which standards provide clear descriptions of data elements?

answer

vocabulary

question

What part of the medical record is reviewed during a utilization review?

answer

progress notes

question

Voluntarily meeting very high standards that measure and ensure the quality of healthcare services is called:

answer

accreditation

question

Terminal digit filing works best for what size of facility?

answer

larger

question

Required signatures, patient name and MR# present on every page, and missing reports are all checked in what type of analysis?

answer

quantitative

question

PPOs must meet the standards of what organization?

answer

NCQA

question

What was North America's first hospital?

answer

Pennsylvania hospital

question

One location to admit patients is an example of:

answer

centralization

question

Is a proprietary hospital one that is not-for-profit?

answer

no

question

What part of healthcare administration is responsible for collecting information on who will be responsible for paying the hospital bill?

answer

admitting office

question

What type of filing does not require the use of an index to locate the file? An example would be alphabetic filing.

answer

direct

question

Fixed rules that must be followed are called:

answer

standards

question

Identifying patients that have been seen and/or treated at the facility is called:

answer

case finding

question

HIPAA mandated the collection of information on healthcare fraud and abuse. This resulted in the development of what? What does it stand for?

answer

HIPDB, healthcare integrity and protection data bank

question

Programs such as smoking cessation and antidepressant medication management are a focus of what? what does it stand for?

answer

HEDIS, healthcare effectiveness data and information set

question

Medical staff bylaws are established by the:

answer

board of directors

question

A fetal death is "the complete expulsion or extraction of a product of conception with a weight of less than ____ grams".

answer

350

question

What do the initials DRG stand for?

answer

diagnosis related group

question

What organization's mission is to ensure the quality, efficiency, and cost-effectiveness of services provided to Medicare patients?

answer

JCAHO

question

Ambulatory care is not provided in which setting?

answer

hospice

question

DEEDS stands for what, and collects data from what care setting?

answer

data elements for emergency departments, emergency departments

question

Which care setting is associated with OASIS-C?

answer

home health

question

What does OASIS stand for?

answer

outcome and assessment information set

question

What database looks at issues related to cost of treatments, the extent to which treatments are used, and the outcomes and costs for alternative treatments?

answer

HCUP

question

What does AHRQ stand for?

answer

agency for healthcare research and quality

question

What organization accredits HIM programs?

answer

CAHIIM

question

What does HCUP stand for?

answer

healthcare cost and utilization project

question

The filing system that uses the least number of folders is:

answer

unit numbering

question

Who develops AHIMA's policies?

answer

volunteers

question

Alpha-numeric filing works best in what size of facility?

answer

small

question

Who approves the operating budget and is responsible for the business affairs of AHIMA?

answer

board of directors

question

The expected data values; the acceptable values or value ranges are classified as:

answer

precision

question

In the hospital, whose responsibility is the approval of the organization and composition of the medical staff?

answer

board of directors

question

The annual licensure of a healthcare facility comes from who?

answer

individual states

question

The protection of health information from loss, damage, unauthorized use, and unauthorized alterations is:

answer

security

question

The clearinghouse for information about medical practitioners who have a history of malpractice suits and other quality problems is the:

answer

NPDB

question

What is a major contributing factor behind the passage of HIPAA?

answer

need for standardization of software and technology

question

Allowing data to be easily, accurately, and securely communicated electronically among various computer systems is called:

answer

interoperability

question

Can certificates (birth/death) be signed with a rubber stamp?

answer

no

question

What is used for research and education purposes and to direct the location of health information in order to provide information to third parties?

answer

index

question

Third party payers, government agencies, and accreditation organizations are all examples of:

answer

external users

question

A forms check for consistency assures that:

answer

all combinations of data are correct

question

A H&P must be completed and documented in how many hours after admission. When else is it needed?

answer

24, before operation requiring anesthesia

question

A physician can simply update a H&P if it was completed in the last _____ days.

answer

30

question

What does CTR stand for?

answer

cancer tumor registrar

question

What two numbering/filing systems assign a new number at each admission?

answer

serial and serial unit

question

Will the DHHS accept a carbon copy or xerox copy of a birth certificate for filing with the state?

answer

no

question

What is placed in the record location when it is removed, is the most common type of tracking system for paper-based records, is the size of a regular folder, and is made of vinyl with two pockets?

answer

outguide

question

What two individuals are responsible for completing the cause of death on a death certificate?

answer

coroner or physician

question

The chronological list of patients having surgery each day is known as an:

answer

OR registry

question

Standards that provide the rules, called protocols, for data transmission from one computer to another are:

answer

technical standards

question

An edit message just popped up on your screen. It is telling you that something is wrong with the data:

answer

validity

question

An audit trail is a check for data:

answer

security

question

How often are assessments performed in LTC?

answer

every 90 days, annually, and with any significant change

question

The account of a patient's illness, course of treatment, response to treatment, and condition at discharge are found in the:

answer

discharge summary

question

The progression of facilities involved in the care of the patient is referred to as:

answer

continuum of care

question

OASIS is part of which care setting? OASIS-C is part of which care setting?

answer

LTC, home health

question

Admission record and face sheet are two other names for the:

answer

summary sheet

question

What is the largest healthcare standards-setting body in the world?

answer

JCAHO

question

What are the 3 previous names of AHIMA?

answer

AAMRL, ARLNA, and AMRA

question

Medicare and Medicaid patients undergo what process to ensure that services provided are medically necessary?

answer

utilization review

question

What element is not included in patient identification?

answer

age

question

A widespread network of healthcare providers is called an:

answer

IDS

question

What does IDS stand for?

answer

integrated delivery system

question

RAPs are part of a:

answer

RAI

question

What care setting is associated with UHDDS?

answer

acute care hospitals

question

What is the title of the person who manages the security of electronically maintained information and promotes policies for promoting security?

answer

information security manager

question

In the PPS, DRG payment is based upon what?

answer

diagnosis

question

Can a hospital make copies of a birth certificate?

answer

no

question

Birth defects registries are most often _______ based.

answer

population

question

Cancer programs are surveyed and approved by what organization?

answer

American college of surgeons

question

A compact shelf filing system on tracks requires how many isles?

answer

one

question

Data is reliable; it doesn't change no matter how it is stored, processed, or displayed refers to:

answer

consistency

question

EMDS (Emergency Managment Data Set) is associated with:

answer

DEEDS

question

Patient safety, consumer protection, access to services, and continuous improvement are among the focus of managed care and PPOs of the:

answer

AAAHC (accreditation association for ambulatory health care)

question

Healthcare organizations accredited by TJC are also considered to be in compliance with Medicare CoP. This is referred to as:

answer

deemed status

question

A data element you would expect to be collected in the MDS but not in the UHDDS would be:

answer

cognitive patterns

question

Engaging patients and their families in healthcare decisions is one of the core objectives for what?

answer

meaningful use

question

For continuity of care, ambulatory care providers are more likely than acute care providers to rely on documentation found in the:

answer

problem list

question

The best place to locate information regarding menstrual history, number of pregnancies, and number of living children would be the:

answer

prenatal record

question

Ultimate responsibility for the quality and completion of entries in patient health records belongs to whom?

answer

attending physician

question

The federally mandated resident assessment instrument used in long-term facilities consists of three basic components: new care area assessment, utilization guidelines, and the:

answer

MDS

question

In order to keep abreast of changes in ARRA and HITECH, one must regularly access the website of the:

answer

ONC

question

As part of TJC's National Patient Safety Goals initiative, acute care hospitals are now required to use a preoperative verification process. Along with this, they must also develop and use a process for:

answer

marking the surgical site

question

The health record states that the patient is female, but the registration record has them listed as male. What data quality characteristic has been compromised?

answer

accuracy

question

A patient presents to the ER due to a vehicle accident. According to their family, the patient had a recent medical history taken at the public health department. The physician can use this for treatment, but he must access it through what?

answer

RHIO

question

TJC states that the number of delinquent records should not be greater than ________%, and that records delinquent due to missing H&P's shall not exceed ____%.

answer

50, 2

question

"Patient states low back pain is as severe as it was on admission" is an example of a ___________ statement.

answer

subjective

question

A physical assessment would be an example of a _____________ entry in a health record.

answer

objective

question

____________ means it is observed by the physician, and _____________ means it is stated by the patient.

answer

objective, subjective

question

One essential item to be captured on the physical exam would be the:

answer

general appearance

question

Checking for the presence or absence of items such as preoperative and postoperative diagnoses, findings, and specimens removed would be an example of what type of record review?

answer

qualitative

question

_______________ record review goes in-depth, whereas _______________ review focuses on the record as a whole.

answer

qualitative, quantitative

question

Palliative care is least likely to be provided by a facility that is accredited by what organization?

answer

CARF

question

Exchange of health information across the continuum withing a geographical community is done through use of a:

answer

RHIO

question

RHIO stands for what?

answer

regional health information organization

question

CARF stands for what?

answer

Commission on Accreditation of Rehab Facilities

question

Accreditation by TJC is a voluntary activity, however, it may be required for what?

answer

reimbursement

question

What is a permanent log of all cases entered into a database?

answer

accession register

question

Annual caseloads can be easily retrieved using what?

answer

accession register

question

A pattern of inconsistent data entries when comparing documentation of the same data elements reveals that data ___________ is being compromised.

answer

reliability

question

Medicare rules state that verbal orders should be infrequent, but when necessary, they must be :

answer

recorded by persons authorized

question

For home health services, a summary should be reviewed and updated every _______ days.

answer

60

question

A review of systems differs from a physical exam because it:

answer

mentions symptoms the patient may have forgotten or did not feel was relevant

question

Skilled nursing facilities may choose to submit MDS data using RAVEN software, or commercially processed software, given that it meets what organization's standards?

answer

CMS

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